Pneumothorax

Question 1

Pneumothorax

Answer 1

Accumulation of air in the pleural space causing lung

collapse due to loss of surface tension

Question 2

Classification

Answer 2

Closed: intact chest wall and air leaks from lung into
pleural cavity

Open: defect in the chest wall allows communication
between pleura and exterior: may be sucking.

Tension: air enters pleural cavity through one-way valve and cannot escape → mediastinal compression

Question 3

Causes

Answer 3

Spontaneous:
• Primary

• Secondary: underlying lung disease

• COPD
• Marfan’s, Ehler’s Danlos
• Pulmonary fibrosis, sarcoidosis

Trauma:

• penetrating
• blunt trauma + #ribs

Iatrogenic

Question 4

Presentation

Answer 4

Symptoms:

• Sudden onset dyspnoea
• Pleuritic chest pain

Signs:

• Reduced chest expansion
• Resonant percussion
• ↓ breath sounds
• ↓VR
• hypoxia
• Ipsilateral boundary of lung seen on CXR

Question 5

Tension pneumothorax presentation

Answer 5

Symptoms:

• Sudden onset dyspnoea
• Pleuritic chest pain
• Respiratory distress
• Cardiac arrest

Signs:

• Raised JVP
• Mediastinal shift away
• Tachycardia
• Hypotension

Question 6

Ix

Answer 6

Respiratory examination 
Basic obs 
Bloods - FBC, U+Es, CRP
ABG
CXR 
CT - bullae

Do not investigate if tension pneumothorax is suspected

Question 7

CXR signs

Answer 7

Atelectasis - loss of lung markings
Hyper-resonant

Tension:
Mediastinal shift away

Question 8

Mx of tension pneumothorax

Answer 8

1. Resuscitation
2. No CXR
3. Aspirate to decompress - large bore venflon cannular into 2nd ICS mid clavicular line
4. ICD - intercostal chest drain

Question 9

Mx of primary spontaneous pneumothorax

Answer 9

Size >2cm or breathless - aspirate

Smaller than 2cm or no breathless - discharge and follow up in outpatients in 2 - 4 wks

If aspiration is unsuccessful - chest drain

Question 10

Mx of secondary spontaneous pneumothorax

Answer 10

Size >2cm or breathless - chest drain

1- 2cm or no breathless - aspirate

Less than 1cm - admit with high flow oxygen and observe for 24hrs

Question 11

Primary pneumothorax

Answer 11

No underlying lung disease

• Young, thin, tall men (ruptured subpleural bulla)
• Smokers

Question 12

When to aspirate pneumothorax

Answer 12

If greater than 2cm and/or breathless in primary pneumothorax
If 1 - 2 cm in secondary pneumothorax

Question 13

When to do chest drain

Answer 13

Secondary pneumothorax 2+ cm or breathless

Question 14

Where to put chest drain

Answer 14

5th intercostal space mid axillary line (safe triangle)

ABOVE rib

Question 15

Safe triangle borders

Answer 15

Posterior and lateral border - Latissimus dorsi
Medial border - Pectoralis major
Inferior border - in line with nipples
Superior - axillary fold

Question 16

Risk factors for pneumothorax

Answer 16

Primary: 
Tall, thin male 
Ehlos Danlos 
Marfans syndrome 
Smoker 

Secondary: 
COPD 
Asthma 
TB 
Pneumocystis jirovecii 
Cystic fibrosis